Infant Feeding Decision-Making and the Influences of Social Support Persons Among First-Time African American Mothers

Why do mothers mix milk feed their infants? Results from a systematic review

CONTEXT

Combining or supplementing breastfeeding with formula feeding, also called mixed milk feeding (MMF), is a common infant feeding practice. However, there is no well-established MMF evidence-base for informing and guiding parents. A better understanding of the reasons why mothers practice MMF may facilitate identification of efficient strategies for supporting exclusive breastfeeding, and/or opportunities to prolong breastfeeding, at least partially.

OBJECTIVE

An updated systematic literature review was undertaken with the primary aim of gaining a deeper understanding of the reasons why mothers choose MMF.

DATA SOURCES

Six databases were searched for relevant articles published in English from January 2012 to January 2022.

DATA EXTRACTION

Two reviewers independently performed the screenings and data extraction, and any differences were resolved by a third reviewer. Data from 138 articles were included, 90 of which contained data on MMF reasons/drivers, and 60 contained data on infant age and/or maternal demographic factors associated with MMF.

DATA ANALYSIS

A total of 13 different unique MMF drivers/reasons were identified and categorized according to whether the drivers/reasons related to perceived choice, necessity, or pressure. Risk of bias was evaluated using the Quality Assessment Tool of Diverse Studies and the JBI Systematic Reviews tool. Several different terms were used to describe and classify MMF across the studies. The most commonly reported reasons for MMF were related to a perception of necessity (39% of drivers, eg, concerns about infant's hunger/perceived breast milk insufficiency or breastfeeding difficulties), followed by drivers associated with perceived choice (34%; eg, having more flexibility) and perceived pressure (25%; eg, returning to work or healthcare professionals' advice). This was particularly true for infants aged 3 months or younger.

CONCLUSION

The key global drivers for MMF and their distribution across infant age and regions were identified and described, providing opportunities for the provision of optimal breastfeeding support. A unified definition of MMF is needed in order to enable more comparable and standardized research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022304253.

Behaviour change communication to improve complementary feeding practices in Ethiopia: Couples' beliefs concerning paternal involvement in childcare

An important cause of stunting is limited consumption of complementary foods, in terms of both quantities and nutrients. Although existing studies show a positive association between fathers' engagement and children's diet, programmes designed to improve complementary feeding practices often only target mothers. In response to this, maternal behaviour change communication (BCC), paternal BCC and food voucher programmes were designed and implemented in Ethiopia using a clustered randomized controlled trial design. The paternal BCC programme included gender-equal messages to increase fathers' participation in childcare, household labour and decision making. The research reported in this paper is an examination of the BCC programmes, characterizing the behavioural, normative and control beliefs of both mothers and fathers in BCC households compared to those in control households. In this study, a total of 40 participants were included, with 13 mother-father pairs in the BCC + food voucher group, and seven pairs in the control group. Each participant was interviewed separately. We found that BCC mothers showed more gender-equal tendencies than the control mothers despite being more rural in location. By contrast, the beliefs of BCC and control fathers were similar overall, suggesting men are more resistant to gender-equal BCC. More work is needed to develop and test effective methods for changing fathers' beliefs and practices.

Experiences of breastfeeding peer counseling among women with low incomes in the US: a qualitative evaluation

BACKGROUND

Person-centered breastfeeding counseling is a key but often overlooked aspect of high-quality services. We explored women's experiences of the Breastfeeding Heritage and Pride™ program, an evidence-based breastfeeding peer counseling program serving women with low incomes in the United States.

METHODS

This study was conducted through an equitable community-clinical-academic partnership and guided by the World Health Organization (WHO) quality of care framework for maternal and newborn health, which highlights three domains of positive experiences of care: effective communication; respect and dignity; and emotional support. In-depth interviews were conducted with a purposive sample of women participating in the Breastfeeding Heritage and Pride™ program. Women were asked to describe their experiences with the program including examples of when good quality counseling was or was not provided. Each interview was conducted in English or Spanish, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Once themes were generated, they were organized according to the three care experience domains in the WHO quality of care framework.

RESULTS

Twenty-eight in-depth interviews were conducted with a racially/ethnically and socio-economically diverse sample of women. Three themes described effective communication practices of peer counselors: tailoring communication to meet women's individual needs; offering comprehensive and honest information about infant feeding; and being timely, proactive, and responsive in all communications across the maternity care continuum. Two themes captured why women felt respected. First, peer counselors were respectful in their interactions with women; they were courteous, patient, and non-judgmental and respected women's infant feeding decisions. Second, peer counselors showed genuine interest in the well-being of women and their families, beyond breastfeeding. The key theme related to emotional support explored ways in which peer counselors offered encouragement to women, namely by affirming women's efforts to breastfeed and by providing reassurance that alleviated their worries about breastfeeding. These positive experiences of counseling were appreciated by women.

CONCLUSIONS

Women described having and valuing positive experiences in their interactions with peer counselors. Efforts to expand access to high-quality, person-centered breastfeeding counseling should, as part of quality assurance, include women's feedback on their experiences of these services.

Determinants of health care worker breastfeeding experience and practices and their association with provision of care for breastfeeding mothers: a mixed-methods study from Northern Thailand

BACKGROUND

Improving breastfeeding rates is one of the most cost-effective ways to prevent infant deaths, but most of the world falls far below WHO recommended breastfeeding practices. Confident, informed healthcare workers are an important resource to promote breastfeeding, but healthcare workers are at risk of early breastfeeding cessation themselves. Culture, ethnicity and socio-economic status impact breastfeeding rates with some of the highest and lowest rates in Southeast Asia reported from Thailand. This study explores the relationship between workplace determinants of breastfeeding, personal breastfeeding outcomes for healthcare workers, and the breastfeeding care healthcare workers provide their patients.

METHODS

This study used a sequential exploratory design guided by a conceptual framework based on social ecological/ecological psychology models. Participants came from four clinical sites in Northern Thailand, from ethnically Burman or Karen communities with high breastfeeding rates, and Thai communities with low breastfeeding rates. In-depth interviews (July 2020-November 2020) were followed by a quantitative survey (November 2020-July 2021) derived from validated questionnaires (Australian Breastfeeding Knowledge and Attitudes Questionnaire and the Workplace Breastfeeding Support Scale) with minor local adaptations.

RESULTS

Interviews highlighted the beneficial effects of supportive workplace policies, the importance of physical spaces to facilitate proximity between mothers and infants, and the problem of low milk production. Meeting the WHO recommended practices of exclusive breastfeeding to 6 months or total breastfeeding to 2 years or more was more common in sites with higher levels of breastfeeding support (aOR 7.3, 95%CI 1.8, 29.1 for exclusive breastfeeding). Exclusive breastfeeding was also higher when staff set breastfeeding goals (aOR 4.4, 95%CI 1.7, 11.5). Staff who were able to see their infants during the work day were less likely to terminate breastfeeding because of work (aOR 0.3, 95%CI 0.1, 0.8). Staff who met both WHO recommendations themselves were more likely to report high levels of confidence caring for breastfeeding patients (aOR 2.6, 95%CI 1.1, 6.4).

CONCLUSIONS

Workplace protections including supportive maternity leave policies and child-friendly spaces can improve breastfeeding outcomes for healthcare workers. These improved outcomes are then passed on to patients who benefit from healthcare workers who are more confident and attentive to breastfeeding problems.

A complex intervention to support breastfeeding: A feasibility and acceptability study

AIMS

The aims of this study are to assess the acceptability and feasibility of a multicomponent intervention to support breastfeeding women and their families and explore its effectiveness.

METHODS

A pilot study with control and intervention groups was conducted using the complex intervention framework in two primary healthcare centres. Overall, 44 childbearing women, their partners/relatives and 20 healthcare professionals participated in the study. The intervention's feasibility and acceptability were measured. The percentage of exclusive breastfeeding rates and women's self-efficacy were measured at pre-intervention, at 10 days postpartum, and again at 2, 4 and 6 months postpartum. Postpartum depression risk was measured at 2 and 6 months postpartum. Professional self-efficacy was measured at pre-intervention and 3 months later.

RESULTS

The intervention was feasible and acceptable. No difference in self-efficacy existed between the intervention and control groups. Preliminary effects of the intervention were found in exclusive breastfeeding percentage and postpartum depression risk in the intervention group.

CONCLUSION

The intervention is feasible and acceptable. The results are promising not only for breastfeeding maintenance but also for preventing postpartum depression and recovering exclusive breastfeeding during pandemics.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03944642.

How Resources Combining Expertise and Social Support Help Breastfeeding Women Address Self-Doubt and Increase Breastfeeding Self-Efficacy: A Mixed-Methods Study

Existing research on parental information literacy focuses on parents' ability to evaluate information. This approach does not account for conflicting or unwanted information and obscures the emotional impact of unsought information. We aimed to (1) document the sources women use most frequently for accessing breastfeeding information, (2) explore the reasons women choose some sources over others, (3) test the relationship between source characteristics and breastfeeding self-efficacy, and (4) determine the extent to which four source characteristics - competence, trustworthiness, goodwill, and social support - predict breastfeeding self-efficacy. This study was conducted in two phases. The first phase consisted of interviews and focus groups, which we analyzed inductively using a grounded theory approach. In phase two, we conducted a cross-sectional survey of women who were currently breastfeeding, collecting data on the source credibility and social support associated with the source they use most frequently and the participants' breastfeeding self-efficacy. We used multiple regression to analyze our survey data. The frequency with which our participants encountered conflicting and unsought prompted them to view sources that combine expertise and social support as ideal. However, these sources are often difficult to access, leading to a reliance on online sources. This compromise has implications for breastfeeding tenure, as both competence and social support predicted breastfeeding self-efficacy. This study demonstrates how emotional aspects of information seeking shape women's preferred sources, how accessibility limits the use of preferred sources, and how source competence and social support influence breastfeeding self-efficacy.

Factors influencing breastfeeding continuation and formula feeding beyond six months in rural and urban households in Indonesia: a qualitative investigation

BACKGROUND

Global and Indonesian guidelines suggest that breastfeeding should continue for at least the first two years of life. While many studies have focused on six-month exclusive breastfeeding practices, little is known about why mothers do not sustain breastfeeding beyond this period. This qualitative study aimed to explore factors influencing breastfeeding continuation and formula feeding beyond six months, regardless of any additional food consumed, focusing on Indonesia's rural and urban areas.

METHODS

We collected the data through 46 in-depth interviews in Pati District and Surakarta City, Central Java, Indonesia. Participants were mothers, grandmothers, health care practitioners, and village kader (frontline female health workers). We used thematic analysis combining deductive and inductive techniques for analysing the data.

RESULTS

Rural mothers practised breastfeeding and intended to breastfeed for a longer duration than urban mothers. Maternal attitude towards breastfeeding, breastfeeding knowledge, previous experiences, and other breastfeeding strategies (e.g., enhancing maternal dietary quality) positively influenced breastfeeding sustainability. In the urban setting, mothers encountered several breastfeeding barriers, such as perceived breast milk insufficiency and child hunger and satiety, child biting, and breastfeeding refusal, causing them to provide formula milk as a breast milk substitute or supplement. In addition, families, communities, health practitioners, and employment influenced maternal decisions in breastfeeding continuation and formula-feeding practices.

CONCLUSIONS

Optimal breastfeeding practices up to two years of age are determined by the individual and setting (i.e., community, healthcare, employment) factors. Providing breastfeeding education covering practical breastfeeding guidance will encourage mothers to breastfeed for longer. Such interventions should involve families, communities, health workers, and the work environment as a breastfeeding support system. Policymakers should develop, enforce, and monitor the implementation of breastfeeding policies to protect, promote, and support breastfeeding in households, communities, health systems, and work settings.

A correlational study of breastfeeding duration among Saudi mothers: The role of self-efficacy, intention, and social support

Background

Breastfeeding is an essential source of nutrition for infants and offers numerous benefits for both the mother and child. Despite the consensus on its advantages, limited research in Saudi Arabia has explored the factors influencing breastfeeding duration.

Objective

This study aimed to examine the relationships between breastfeeding self-efficacy, intention, social support, and breastfeeding duration.

Methods

The study employed a correlational research design, and data were collected from three armed forces hospitals in Taif, Saudi Arabia, from December 2020 to February 2021. The samples comprised 356 conveniently selected breastfeeding mothers, assessed using the Breastfeeding Personal Efficacy Beliefs Inventory, Modified Infant Feeding Intention Scale, and Exclusive Breastfeeding Social Support Scale. Simple linear regressions were conducted for data analysis.

Results

Breastfeeding duration was divided into two groups. Group 1 consisted of mothers still breastfeeding at the time of data collection, while Group 2 comprised those who had discontinued breastfeeding. Of the total samples, 51.6% (n = 184) of mothers were classified under Group 1, while the remaining 48.4% (n = 172) were allocated to Group 2. Specifically, 78.3% of mothers had stopped breastfeeding by the time their infants were six months old, and 93.3% intended to introduce formula feeding at three months. In Group 1, the results revealed that self-efficacy (β = 0.625, p <0.001), intention (β = 0.643, p <0.001), and social support (β = 0.612, p <0.001) were positively associated with breastfeeding duration. Similarly, in Group 2, a strong positive correlation was observed between self-efficacy (β = 0.72, p <0.001), intention (β = 0.73, p <0.001), social support (β = 0.699, p <0.001), and breastfeeding duration. These three factors jointly explained 40% of the variance in breastfeeding duration in Group 1 (adjusted R2 = 0.4) and 50% in Group 2 (adjusted R2 = 0.5).

Conclusion

Breastfeeding intention was found to have a more significant impact on breastfeeding duration than self-efficacy and social support. These results can inform nurses and midwives in supporting breastfeeding mothers by providing them with the necessary information and increasing their awareness of breastfeeding-related factors.

Community-based approaches to infant safe sleep and breastfeeding promotion: a qualitative study

BACKGROUND

In the U.S., sudden unexpected infant deaths (SUID) due to accidental suffocation and strangulation in bed (ASSB) are increasing, with disparities by race/ethnicity. While breastfeeding is a protective factor against infant mortality, racial/ethnic disparities are present in its uptake, and motivations to breastfeed are also often coupled with non-recommended infant sleep practices that are associated with infant sleep deaths. Combining infant safe sleep (ISS) and breastfeeding promotion on the community level presents opportunities to address racial/ethnic disparities and associated socioeconomic, cultural, and psychosocial influences.

METHODS

We completed a descriptive qualitative hermeneutical phenomenology using thematic analysis of focus group data. We examined the phenomenon of community-level providers promoting ISS and breastfeeding in communities vulnerable to ISS and breastfeeding disparities. We asked eighteen informants participating in a national quality improvement collaborative about i.) areas requiring additional support to meet community needs around ISS and breastfeeding, and ii.) recommendations on tools to improve their work promoting ISS and breastfeeding.

RESULTS

We identified four themes: i.) education and dissemination, ii.) relationship building and social support, iii.) working with clients' personal circumstances and considerations, and iv.) tools and systems.

CONCLUSIONS

Our findings support embedding risk-mitigation approaches in ISS education; relationship building between providers, clients, and peers; and the provision of ISS and breastfeeding supportive material resources with educational opportunities. These findings may be used to inform community-level provider approaches to ISS and breastfeeding promotion.

Breastfeeding Social Support Among African American Women in the United States: A Meta-Ethnography

BACKGROUND

In the United States, there are racial disparities in 6 months of exclusive breastfeeding. Only, 25.8% of American infants were breastfed for the first 180 days of life, with African American infants least (19.8%) exclusively breastfed in 2018.

PURPOSE

The meta-ethnography explored the breastfeeding support for African American women in the United States.

DATA SOURCES

The online databases of American Psychological Association, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Scopus were searched with key words, and the search was not limited by the year of publication.

STUDY SELECTION

The inclusion criteria for the study selection entailed all qualitative studies conducted on breastfeeding support among self-identified African American women in the United States, written in English language, peer reviewed, or dissertation. The initial search produced 905 articles of which 8 met the eligibility criteria.

DATA EXTRACTION

Data extraction and analysis were guided by Noblit and Hare's (1988) meta-ethnography approach. The analysis process was completed by a team of researchers, inclusive of breastfeeding experts.

RESULTS

Five overarching themes emerged including trustworthy information; early postpartum support by key influencers; maternal culture; tangible resources, and Black mothers' empowerment.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Social support is a major determinant for the initiation and continuation of breastfeeding among African American women in the United States. Future longitudinal studies are warranted to explore the social support of breastfeeding among African American women in the United States.

Forming the Perception of WIC Infant Feeding Recommendations: A Qualitative Study

Nearly half of newborns in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Promoting breastfeeding is a programmatic priority, although formula vouchers are provided for those who do not exclusively breastfeed. Previous literature suggests that participant perception of WIC's breastfeeding recommendations is a significant factor predicting breastfeeding initiation, duration, and exclusivity outcomes. However, little is known about how participants' perceptions of WIC's breastfeeding recommendations are formed. To address this knowledge gap, we conducted a qualitative pilot study in Nevada, interviewing 10 postpartum WIC mothers and 12 WIC staff who had interacted with participants regarding infant feeding. Results showed participants and staff reported various perceptions of what WIC recommends, the factors that contribute to these perceptions, and how these perceptions affect breastfeeding practices. Respondents also described that WIC has a negative legacy as the "free formula program," and that environmental factors, such as the recent formula recall, have had an impact on participants' infant feeding practices. More effective public campaigns and programmatic strategies are needed to target participants' prenatal self-efficacy and to communicate the availability of skilled lactation support in the early postpartum period to improve participants' perceptions of WIC's position on breastfeeding.

Effects of spousal support in the early postpartum period on breastfeeding motivation in patriarchal societies

Background and Purpose: Breastfeeding is important with regard to public health. Our aim was to examine effects of spousal support in the early postpartum period on breastfeeding motivation in patriarchal societies. Methods: Study was descriptive, cross-sectional, correlational design. Study was conducted in a University Hospital in Inland Anatolia Region in Turkey. It included primiparous and multiparous women. Results: Analysis showed a significant positive, moderate relation between spousal support and breastfeeding motivation in the primiparous women; spousal support accounted for 23.8% of breastfeeding motivation of the women. There was a significant, positive weak relation between spousal support and breastfeeding motivation in the multiparous women; spousal support explained 8.2% of breastfeeding motivation in these women. Conclusion: Spousal support in the early postpartum period was found to have a positive influence on improvement of breastfeeding motivation. However, it could explain a small percentage of breastfeeding motivation. New strategies should be created to encourage spouses to get involved in breastfeeding.

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records

Introduction

The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs).

Materials and Methods

A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery.

Results

Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers.

Conclusions

Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

Prenatal Perception of WIC Breastfeeding Recommendations Predicts Breastfeeding Exclusivity and Duration in the Infants' First Year

BACKGROUND

Pregnant participants who perceived that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) recommends breastfeeding only were more likely to have better early breastfeeding outcomes.

OBJECTIVES

Our objective was to examine the association between prenatal perception of WIC's breastfeeding recommendations and breastfeeding duration through the first year of infant life.

METHODS

This observational study used a national longitudinal sample of 1594 pregnant participants in the WIC Infant and Toddler Feeding Practices Study-2 in 2013. Four measures of breastfeeding duration were used: 1) a discrete measure of exclusive breastfeeding through 5 mo; 2) a continuous measure of exclusive breastfeeding (in days up to 7 mo); 3) a discrete measure of any breastfeeding through 11 mo; and 4) a continuous measure of any breastfeeding (in days up to 13 mo). The primary explanatory variable was the participant's prenatal perception of whether WIC recommended breastfeeding only. The univariate analyses of time to breastfeeding cessation were performed using Kaplan-Meier curves. The Cox regression model was adopted to estimate the likelihood of breastfeeding outcomes over time. All analyses accounted for complex survey design effects.

RESULTS

Compared with their peers who perceived WIC to recommend formula only or both breastfeeding and formula equally, participants who perceived WIC as recommending breastfeeding only were less likely to stop exclusive breastfeeding through 5 mo (HR = 0.83; 95% CI: 0.69, 0.99) or to stop any breastfeeding through 11 mo (HR = 0.80; 95% CI: 0.69, 0.92), without controlling for prenatal infant feeding intentions. Similar patterns were observed in the 2 continuous measures, as they were also less likely to stop exclusive breastfeeding by 7 mo (HR = 0.78; 95% CI: 0.69, 0.90) or to stop any breastfeeding by 13 mo (HR = 0.82; 95% CI: 0.71, 0.95).

CONCLUSIONS

Prenatal perception of WIC's breastfeeding recommendation can be a useful predictor of breastfeeding duration in WIC participants.

Receiving screened donor human milk for their infant supports parental wellbeing: a mixed-methods study

BACKGROUND

Access to donor human milk (DHM) has primarily been based on the health and development outcomes of premature infants but there has been little examination of the broader impact of an infant receiving it upon parental mental health. Breastfeeding and mental health are closely tied with women who experience breastfeeding difficulties or are unable to meet their own breastfeeding goals often experiencing feelings of guilt, sadness and anger, alongside an increased risk of postnatal depression. The aim of the current study was to explore how experience of receiving DHM for their baby affected the wellbeing of parents.

METHODS

UK parents of infants aged 0 - 12 months who had received screened DHM from a milk bank (typically on the neonatal unit or in some cases in the community) completed an online questionnaire exploring their experiences. The questionnaire included Likert scale items examining perceived impact upon infant health, own wellbeing and family functioning alongside open-ended questions exploring perceptions of how receiving DHM affected wellbeing.

RESULTS

Almost all of the 107 participants (women = 102) agreed that receiving DHM had a positive impact upon infant health and development, their own mental and physical health, and their family's wellbeing. Parents felt relieved that their infant was receiving DHM for health reasons but also due to the experience of being listened to, supported and having their infant feeding decisions facilitated. Receiving DHM helped mothers to process some of their emotions at not being able to breastfeed, in part because knowing their baby was being fed gave them the space to focus on recovery and bonding with their baby. Some parents did experience challenges, feeling guilty at receiving DHM, insecure that another woman was able to feed their baby when they could not, or negative reactions from family. Although the impact of receiving DHM upon breastfeeding was not measured, some women who were working to build their own milk supply noted that it helped motivate them to continue.

CONCLUSIONS

DHM may play an important role not only in protecting infant health and development but in supporting the mental health and wellbeing of mothers for whom their infant receiving human milk is important.

Exclusive breastfeeding in African American women: A concept analysis

AIM

To report an analysis of the concept of exclusive breastfeeding (EBF) in African American women.

BACKGROUND

EBF is the gold standard for infant nutrition from birth until 6 months. The rate of EBF in United States is low-26%, with African American women having the lowest rates. The low rates of EBF in this population are strongly attributed to bias, racism and generational trauma. Therefore, clarifying the concept of EBF with respect to these factors is important for promoting EBF rates of this population.

DESIGN

Concept analysis.

DATA SOURCES

Search was conducted in four databases (CINAHL, PubMed, PsycINFO and Scopus) for articles published between 2001 and 2021. A total of 30 articles (20 quantitative, seven qualitative and three mixed methods) clarified the concept. Relevant literature emanated from diverse disciplines examining historical and present maternal and infant health.

METHODS

Concept analysis using Rodger's evolutionary method.

RESULTS

An operational definition of the concept of EBF in African American women was developed from the identified antecedents (modifiable and non-modifiable), defining attributes and consequences of the concept. Access to breastfeeding resources, maternal (prenatal intention to breastfeed, smoking status, attitude towards breastfeeding), infant (skin-to-skin care, successful latching and weight) and contextual factors (socioeconomic, occupational and cultural) predict EBF. The primary attributes of EBF were physiological, physical, psychological and relational. Consequences of EBF were positive health outcomes for, and increased bonding between, mother and infant.

CONCLUSION

This concept analysis is the first identifying modifiable and non-modifiable antecedents of EBF. The analysis provides an operational definition for EBF in African American women which is useful to promote understanding of breastfeeding. This new concept examines the historic societal trauma associated with wet nursing and reframes breastfeeding as a positive maternal and infant health behaviour.

Facebook Feeds and Child Feeding: A Qualitative Study of Thai Mothers in Online Child Feeding Support Groups

Mothers have traditionally sought child feeding information from social connections. While mothers are heavily engaged on social media and value peer support in online communities, very little is known about how they use online communities for information about child feeding practices after exclusive breastfeeding cessation. This study explores mothers' perceptions of joining Facebook child feeding support groups. Individual semi-structured interviews with ten Thai mothers were conducted. The transcribed interviews were analyzed using a phenomenological hermeneutical approach. Our findings highlighted that Thai mothers participated in Facebook child feeding support groups in a deliberate effort to reduce their uncertainty by normalizing the process through accessing the shared experiences of others. One of their intentions was to seek menu recipes based on favorable psychosocial and environmental factors. Implications for using social media in health promotion and communication include the importance of building appropriate common practices through social collaboration and interactivity to supplement traditional knowledge and attitudes.

Educating fathers to improve exclusive breastfeeding practices: a randomized controlled trial

Background

Fathers’ involvement is crucial for promoting breastfeeding. There are a few studies on the effectiveness of fathers’ educational programs to promote exclusive breastfeeding. This study aims to assess the effectiveness of a fathers’ educational program on their support for breastfeeding, mothers’ breastfeeding practice, and exclusive breastfeeding status.

Methods

This was a randomized controlled trial on 76 fathers who were randomly assigned to two groups of intervention and control, in a selected health center in Iran, 2018.

The tools for data collection were: 1) a questionnaire for “Demographic and Maternal-Infant Information”; 2) a questionnaire to assess “Fathers’ support for Breastfeeding”, and 3) an observational checklist to assess “Mothers’ Breastfeeding Practice”; and 4) a questionnaire to assess “Exclusive Breastfeeding Status”. The questionnaires were filled up through an interview. The checklist was completed through observation by the researcher. The fathers (with the mothers) of the intervention group were educated using individual face-to-face education and counseling, in two sessions, with the duration of about 40 min and one-week interval, whereas, the fathers of the control group did not receive any education and only mothers were educated with the same instruction. The content of the education was: fathers’ education about “benefits of breast milk” and “the supporting ways for breastfeeding including the women encouragement”. Then, the scores of “father’s support for breastfeeding”, “mothers’ breastfeeding practice” and “exclusive breastfeeding status” were compared before and after 4 months of intervention in each group, and also between groups. Data were analyzed using SPPS-23, and t- and paired-tests, Chi-square, and Generalized-Estimating-Equations (GEE) tests.

Results

The results showed two groups were not significantly different regarding the demographic and any other possible confounding variables before the intervention (P < 0.05). The before and after comparisons also demonstrated significant improvements in the two variables including “father’s support for breastfeeding”, and “mothers’ breastfeeding practice after 4 months, in the intervention group (Paired t-test: P<0.001 and P<0.0001, respectively) however, there was a significant decrease in “father’s support for breastfeeding” and no improvement in “mothers’ breastfeeding practice” after 4 months in the control group (Paired t-test: P < 0.001 and P = 0.07, respectively). Between groups comparison showed also significant higher scores for “father’s support for breastfeeding”, “mothers’ breastfeeding practice” and “exclusive breastfeeding status” in the intervention group comparing to the control group, after 4 months (T-test: P < 0.001 and P < 0.0001; Chi2: P < 0.001, respectively). The interaction effects of time and group were significant in the GEE test for the fathers’ support for breastfeeding (B-group = 31.93, B-time = 22.15, p < 0.001) and mothers’ breastfeeding practice (B-group = 26.32, B-time = 12.86, p < 0.0).

Conclusion

The results showed that the father’s education improves mothers’ breastfeeding practice and increases the rate and continuity of exclusive breastfeeding.

Trial registration

IRCT201508248801N10. “31/08/2016”.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07966-8.

A nation‐wide study on the common reasons for infant formula supplementation among healthy, term, breastfed infants in US hospitals

In‐hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in‐hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open‐ended question on the top three reasons for in‐hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in‐hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother‐infant dyads with potential medical and physical indications may reduce unnecessary in‐hospital infant formula supplementation.

The three most commonly reported reasons by hospital staff for infant formula supplementation were found to be related to medical indications (70.0%); maternal request/preference/feelings about breastfeeding such as frustration or lack of confidence (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%); and medical staff/institutional practices (4.7%).

Underlying many of the reported three most common reasons for infant formula supplementation is potentially lack of lactation management support that considers the social influences (e.g. from family and friends) and that is culturally relevant.

These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation.

Effect of Postpartum Yoga on Breastfeeding Self-Efficacy and Maternal Attachment in Primiparous Mothers

Objective: This study was conducted to determine the effect of yoga practice on the breastfeeding self-efficacy and maternal attachment of primiparous mothers in the postpartum period. Methods: This study was performed in a quasi-experimental model with pretest and posttest control groups. The domain of the study was formed with women with 20-40-day-old babies enrolled in two Family Health Centers. One hundred and twenty-four women participated in the study. The Individual Identification Form, Breastfeeding Self-Efficacy Scale, and Maternal Attachment Scale were completed by the experimental and control groups. The experimental group engaged in 60 minutes of postpartum yoga practice 2 days a week for 8 weeks in the company of the researcher. Results: After yoga practice, there was a statistically significant increase in the breastfeeding self-efficacy and improvement in the maternal attachment of the experimental group (p < 0.05). The corresponding increase and improvement of the mothers in the control group were less than those of the mothers in the experimental group (p < 0.05). Conclusion: This study finds that it is beneficial for both the mother's and the baby's physical and psychological health for health professionals to teach mothers to practice yoga, which positively affects breastfeeding and maternal attachment in the postpartum period.

The relationship between maternal perception of social support and breastfeeding patterns

BACKGROUND

Breastfeeding is beneficial for the health of infants and mothers. It is a complex social behavior that may be influenced by social support. The study aimed to determine the relationship between perceived social support of breastfeeding women and their breastfeeding patterns.

MATERIALS AND METHODS

The research was a cross-sectional study on 300 mothers with 6-month infants or younger who were selected randomly. The data collection tool consisted standard social support and breastfeeding patterns questionnaires. We analyzed data using descriptive and analytical tests and SPSS 18 at a significance level of < 0.05.

RESULTS

The results indicated that 85%, 82.2%, and 38% of the infants were exclusively breastfed at 1 week, 4, and 6 months after delivery, respectively. The result of post hoc LSD test indicated that the mean number of supporters for mothers, who were in the 6^th month of delivery, was significantly lower than other times (P = 0.001). The one-way analysis of variance indicated no significant difference between perceived satisfaction of social support at different periods after delivery (P = 0.92). Despite the present results, which indicated that the number of supporters and scores of satisfaction with support in exclusive breastfeeding were higher than other groups, the differences were not statistically significant.

CONCLUSIONS

The mean number of supporters was less in women, who had 6-month-old infants, than mothers who had just given birth. It seems mothers with supplements and formula feeding patterns, such as breastfeeding mothers, may be supported to use these methods. Therefore, more studies are suggested on this field.

African American Mothers' Decision to Discontinue Breastfeeding and Switch to Formula

After initiating breastfeeding, some African American mothers find adjusting to the demands challenging and discontinue breastfeeding. To learn about decisions switching to formula, we conducted a secondary analysis of qualitative interviews with African American mothers ≥ 18 years old. Data were analyzed using thematic analysis guided by the social cognitive theory. We identified four key themes that reflect personal, behavioral, and environmental factors: (1) simplicity of formula, (2) diverse support networks, (3) early breastfeeding is most important, and (4) lack of access to breastfeeding support resources. To increase breastfeeding duration among African American mothers, it is essential for interventions to be comprehensive including various strategies such as education regarding the physical aspects of breastfeeding, exposure to African American breastfeeding mothers, and active involvement of support persons. More research among African American mothers is needed to identify effective opportunities for change in cultural, social, and structural systems that impede successful breastfeeding.

Women's Perceptions and Experiences of Breastfeeding: a scoping review of the literature

BACKGROUND

Despite public health efforts to promote breastfeeding, global rates of breastfeeding continue to trail behind the goals identified by the World Health Organization. While the literature exploring breastfeeding beliefs and practices is growing, it offers various and sometimes conflicting explanations regarding women's attitudes towards and experiences of breastfeeding. This research explores existing empirical literature regarding women's perceptions about and experiences with breastfeeding. The overall goal of this research is to identify what barriers mothers face when attempting to breastfeed and what supports they need to guide their breastfeeding choices.

METHODS

This paper uses a scoping review methodology developed by Arksey and O'Malley. PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched utilizing a predetermined string of keywords. After removing duplicates, papers published in 2010-2020 in English were screened for eligibility. A literature extraction tool and thematic analysis were used to code and analyze the data.

RESULTS

In total, 59 papers were included in the review. Thematic analysis showed that mothers tend to assume that breastfeeding will be easy and find it difficult to cope with breastfeeding challenges. A lack of partner support and social networks, as well as advice from health care professionals, play critical roles in women's decision to breastfeed.

CONCLUSION

While breastfeeding mothers are generally aware of the benefits of breastfeeding, they experience barriers at individual, interpersonal, and organizational levels. It is important to acknowledge that breastfeeding is associated with challenges and provide adequate supports for mothers so that their experiences can be improved, and breastfeeding rates can reach those identified by the World Health Organization.

Maternal guilt and shame in the postpartum infant feeding context: A concept analysis

Background After birth, guilt and shame are differentially experienced by breastfeeding and formula feeding mothers. Despite this, currently utilized guilt and shame definitions lack context specificity, leaving concepts open to misinterpretation. Objective The current study aimed to develop infant feeding-specific definitions of postpartum guilt and shame. Methods Study selection involved a three-stage systematic screening process, outlined in Jackson et al. (2021). Walker and Avant's (2005, 2019) concept analysis framework was then applied to included articles to identify guilt-specific, shame-specific, and overlapping attributes, antecedents, and consequences. Results A guilt-specific, shame-specific, and overlapping definition were generated based on exclusive and overlapping antecedents, attributes, and consequences. Guilt and shame belonged to the empirical referent Moral Emotions, which may explain some of the overlapping antecedents, attributes, and consequences identified during analysis. Conclusions The overlapping definition provides a broad scope for shared characteristics, while specific definitions allow for more in-depth and focused investigations of guilt and shame experiences within an infant feeding context. Utilising context-specific definitions may serve to improve research homogeneity. Shame was found to be uniquely associated with postnatal depression. As such, suggestions are made for future research to further investigate the relationship between shame, infant feeding, and maternal wellbeing outcomes. Implications Identified antecedents may be used by healthcare professionals to provide additional support to mothers at risk of experiencing guilt and shame, to prevent the occurrence and consequences of these emotions.

Examination of Factors That Contribute to Breastfeeding Disparities and Inequities for Black Women in the US

Breastmilk is considered the optimal nutrition for newborns. US Black women continue to have the lowest breastfeeding initiation and duration rates. This Perspective examines factors associated with breastfeeding disparities and inequities among Black women through the lens of critical race theory and the social-ecological model. Recommendations to increase breastfeeding rates in this population include increased communication and educational strategies by health care professionals, education to recognize implicit bias and systemic racism in our health care system, early prenatal and ongoing postpartum breastfeeding support, increased community support, and breastfeeding groups developed by and for Black women. In addition, equity policies such as paid maternity leave and work policies that support milk expression would provide needed institutional support for women in the workplace.

Breastfeeding in Incarcerated Settings in the United States: A National Survey of Frequency and Policies

Objectives: To assess the existence of prison and jail policies and practices that allow incarcerated women to breastfeed while in custody, and prevalence of women in custody who pumped human milk for their infants. Methods: We surveyed 22 state prison systems and 6 county jails from 2016 to 2017 about policies related to breastfeeding and other programs for pregnant and parenting women in custody. In addition, 11 prisons and 5 jails reported 6 months of monthly, prospective data on the number of women pumping human milk, as well as information on placement of infants born to women in custody. Results: Eleven prisons and five jails had policies that supported the practice of expressed milk, either through pumping or breastfeeding. Over 6 months at these sites that allowed lactation, there were 207 women who gave birth in the prisons and an average of 8 women/month who pumped human milk; at the jails, there were 67 women who gave birth and an average of 6 women/month who pumped human milk. Most infants born to women in custody were placed in the care of a family member. Conclusions: Breastfeeding and the provision of human milk are critical public health issues. Our data show inconsistent implementation of policies and practices supportive of breastfeeding in prisons and jails. However, there are institutions in the United States that are supportive of incarcerated women's breastfeeding and lactation needs. Further research is needed to identify the barriers and facilitators associated with implementing supportive breastfeeding policies and practices in the carceral system.

Human Milk for the Term Newborn

Human milk provides optimal nutrition for term newborns, but the prevalence of its use is below target, and risks have been identified. Infants of black mothers as well as term newborns admitted to the neonatal intensive care unit are at risk for not receiving human milk. To improve human milk intake, multiple individual-level interventions have been shown to be effective, but some popular system-level interventions are ineffective or harmful. Expressed milk and donor milk may be less beneficial than direct breastfeeding. Nuanced public policies can help support lactation while promoting individual choice and equity.

The differential role of practical and emotional support in infant feeding experience in the UK

Social support is a known determinant of breastfeeding behaviour and is generally considered beneficial. However, social support encompasses a myriad of different supportive acts, providing scope for diverse infant feeding outcomes. Given the vulnerability of postpartum mental health, this paper aims to explore both how support prolongs breastfeeding and which forms of support promote the positive experience of all infant feeding. Using survey data collected online from 515 UK mothers with infants aged 0-108 weeks, Cox regression models assessed the relationship between receiving different types of support, support need and breastfeeding duration. Quasi-binomial logistic regression models assessed the relationship between receiving support, infant feeding mode and maternal experience of infant feeding. Rates of negative infant feeding experience indicate the widespread need for support: e.g. 38% of currently, 47% of no longer and 31% of never breastfeeding women found infant feeding stressful. Overall, practical support via infant feeding broadly predicted shorter breastfeeding durations and poorer feeding experience; results in relation to other forms of support were more complex. Our findings indicate different forms of support have different associations with infant feeding experience. They also highlight the wide range of individuals beyond the nuclear family on which postpartum mothers in the UK rely. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Breastfeeding Disparities and Their Mediators in an Urban Birth Cohort of Black and White Mothers

Background: Black mothers in the United States have shorter breastfeeding (BF) durations and less exclusive breastfeeding (EBF) than others. The factors underlying these disparities require investigation. Methods: Using longitudinal data from a CDC-sponsored birth cohort in Cincinnati, Ohio, we analyzed the factors mediating racial disparity in BF outcomes. Study mothers were enrolled in prenatal clinics associated with two large birth hospitals. Analysis was restricted to racial groups with sufficient numbers in the cohort, non-Hispanic Black (n = 92) and White (n = 113) mothers, followed to at least 6 months postpartum. Results: Black mothers were 25 times more likely to reside in socioeconomically deprived neighborhoods and 20 times more likely to have an annual household income <$50,000/year than White mothers (p < 0.001). The gap in EBF for 6 weeks was 45 percentage points by racial group (13%-Black mothers versus 58%-White mothers, p < 0.001); in any BF at 6 months was 37 percentage points (28%-Black mothers versus 65%-White mothers, p < 0.001); and in mothers meeting their own intention to BF at least 6 months was 51 percentage points (29%-Black mothers versus 80%-White mothers, p < 0.001). Racial disparity in EBF at 6 weeks was mediated in logistic regression models by inequities in socioeconomic position, maternal hypertension, and BF intention. Racial disparities in BF at 6 months or meeting 6-month BF intention were mediated by inequities in socioeconomic position, maternal obesity, and EBF at 6 weeks. Not all BF disparities could be explained by models used in these analyses. Conclusions: Efforts to lessen BF disparities should address the underlying structural inequities that disproportionately affect Black mothers and children, should incorporate maternal health, and focus on breastfeeding exclusivity and duration. Few Black mothers achieved EBF at 6 weeks, which contributed to disparity in BF duration. Greater attention to Black mother-infant pairs is a public health priority.

Achieving Breastfeeding Equity and Justice in Black Communities: Past, Present, and Future

Background: Breastfeeding is protective of maternal and infant health across the life course. Increasing breastfeeding rates in Black communities is an important public health strategy to address maternal and infant mortality and morbidity. Methods: Data trends for the past 10 years suggest that Black-led community efforts; local, state, and national initiatives; and maternity care practices that are supportive of breastfeeding have been effective in improving and increasing breastfeeding rates among Black women. Results: Yet breastfeeding disparities and inequities in Black communities persist. Systemic and structural barriers, such as racism, bias, and inequitable access to lactation resources and support continue to be issues in the United States. Conclusion: Going forward, significant investments are needed to decolonize breastfeeding research and clinical practice. Public health and policy priorities need to center on listening to Black women, and funding Black, Indigenous, and People of Color (BIPOC) organizations and researchers conducting innovative projects and research.

Racism and Resistance: A Qualitative Study of Bias As a Barrier to Breastfeeding

Background: Nearly 75% of Black non-Hispanic babies born in 2016 ever breastfed. However, Black mothers still experience barriers to breastfeeding, perpetuating disparities in exclusivity and duration. Subjects and Methods: Using data collected from five focus groups with Black mothers (N = 30) in Washington, District of Columbia during summer 2019, we critically examine the influence of institutionalized and personally mediated racism on breastfeeding. We also explore the counter-narratives Black women use to resist oppression and deal with these barriers. Results: Themes surrounding institutionalized racism included historic exploitation, institutions pushing formula, and lack of economic and employment supports. Themes regarding how personally mediated racism manifested included health care interactions and shaming/stigma while feeding in public. At each level examined, themes of resistance were also identified. Themes of resistance to institutionalized racism were economic empowerment and institutions protecting breastfeeding. Themes of resistance to personally mediated biases were rejecting health provider bias and building community. Conclusions: There are opportunities for health providers and systems to break down barriers to breastfeeding for Black women. These include changes in clinical training and practice as well as clinicians leveraging their position and lending their voices in advocacy efforts.

"…[T]his is What We are Missing": The Value of Communicating Infant Feeding Information Across Three Generations of African American Women

BACKGROUND

Breast/Chestfeeding remains a public health issue for African Americans, and increased rates would mitigate many health disparities, thus promoting health equity.

RESEARCH AIMS

To explore the interplay of generational familial roles and meaning (or value) ascribed to communicating infant feeding information across three generations.

METHOD

This prospective, cross-sectional qualitative study used an asset-driven approach and was guided by Black Feminist Thought and Symbolic Interactionism. African American women (N = 35; 15 family triads/dyads), residing in the southeastern United States were interviewed. Data were analyzed using thematic analysis.

RESULTS

The older two generations described their role using assertive yet nurturing terms, while the younger generation carefully discussed the flexibility between their familial roles. Emergent themes described the meaning each generation attributed to communicating infant feeding information: "My Responsibility," "Comforting," "Bonding Experience," "She Cared," and "Gained Wisdom."

CONCLUSIONS

Our findings have potential to contribute to achieving health equity in African American families. Future breast/chestfeeding promotion efforts may benefit from reframing the current approach to including protection language and not solely support language. Lactation professionals should further recognize and support strengths and resource-richness of intergenerational infant feeding communication within African American families using strength-based, empowerment-oriented, and ethnically sensitive approaches.

Moving Beyond Breastfeeding Initiation: A Qualitative Study Unpacking Factors That Influence Infant Feeding at Hospital Discharge Among Urban, Socioeconomically Disadvantaged Women

BACKGROUND

Factors that influence breastfeeding initiation and duration have been well established; however, there is limited understanding of in-hospital exclusive breastfeeding (EBF), which is critical for establishing breastfeeding. Grady Memorial Hospital, which serves a high proportion of participants receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and racial/ethnic minorities, had an in-hospital EBF rate in 2018 by the Joint Commission's definition of 29% and sought contextualized evidence on how to best support breastfeeding mothers.

OBJECTIVE

The objectives were to (1) identify facilitators and barriers to in-hospital EBF and (2) explore breastfeeding support available from key stakeholders across the social-ecological model.

DESIGN

In-depth, semistructured interviews were conducted and analyzed using thematic analysis.

PARTICIPANTS

The sample included a total of 38 purposively sampled participants from Grady Memorial Hospital (10 EBF mothers, 10 non-EBF, and 18 key stakeholders such as clinicians, community organizations' staff, and administrators).

RESULTS

Key themes included that maternal perception of inadequate milk supply was a barrier to in-hospital EBF at the intrapersonal level. At the interpersonal level, a personable and individualized approach to breastfeeding counseling may be most effective in supporting EBF. At the institutional level, key determinants of EBF were gaps in prenatal breastfeeding education, limited time to provide comprehensive prenatal education to high-risk patients, and practical help with latching and positioning. Community-level WIC services were perceived as a facilitator due to the additional benefits provided for EBF mothers; however, the distribution of WIC vouchers for formula to mothers while they are in the hospital undermines the promotion of EBF. Cultural norms and a diverse patient population were reported as barriers to providing support at the macrosystem level.

CONCLUSION

Multipronged approaches that span the social-ecological model may be required to support early EBF in hospital settings.

The role of emotions and injunctive norms in breastfeeding: a systematic review and meta-analysis

Breastfeeding has many known benefits, but rates vary globally. We propose two main reasons why psychological theory and interventions have not been successful to date in explaining breastfeeding behaviours. Specifically, prior research underestimates the importance of (1) specific emotions and (2) wider injunctive influences (i.e., societal and moral norms about what women feel they ought to be doing) in the breastfeeding experience. Therefore, we conducted a systematic review of quantitative, qualitative, and mixed-methods studies that explored whether injunctive norms and/ or specific emotions are associated with breastfeeding behaviours (i.e., intentions, initiation and duration). Seventy-two papers were included in this review; data were extracted and quality appraisals conducted for all included studies. A meta-analysis of effect sizes was performed with the quantitative data. A convergent qualitative synthesis of the data was conducted, resulting in the following line of argument: Breastfeeding is a social behaviour and not a personal/individual behaviour. From this line of argument, three themes with associated sub-themes were developed, highlighting the importance of both specific emotions and injunctive norms on breastfeeding behaviours. These influences are discussed in relation to both theoretical and practical implications, as well as future research.

Black/African American Breastfeeding Experience: Cultural, Sociological, and Health Dimensions Through an Equity Lens

Background: Disparities in breastfeeding (BF) continue to be a public health challenge, as currently only 42% of infants in the world and 25.6% of infants in the United States are exclusively breastfed for the first 6 months of life. In 2019, the infants least likely to be exclusively breastfed at 6 months are African Americans (AA) (17.2%). Materials and Methods: A scoping review of the literature was undertaken by using Arksey and O'Malley's six-stage framework to determine key themes of AA women's experience BF through an equity lens. Electronic databases of CINAHL and PubMed were searched for peer-reviewed, full-text articles written in the English language within the past 5 years by using the terms BF, AA, Black, sociological, cultural, equity, health, attitude, exposure, initiation, continuation, barriers, and facilitators. Results: Initially, 497 articles were identified, and 26 peer-reviewed articles met the eligibility criteria. Through an equity lens, three main themes emerged, which summarized AA women's BF experience: cultural (family, peers and community support; misconceptions; personal factors), sociological (prejudices, racism, home environment; financial status; sexuality issues; BF role models; employment policies), and health dimensions (family involvement; timely and honest information from staff; baby-friendly hospital initiatives; postnatal follow-up; special supplemental nutrition program for women, infants, and children). Conclusion: For AA women, exclusively BF is beset with diverse cultural, health, and sociological challenges. Multifaceted approaches are needed for successful resolution of BF challenges to bridge the racial gap in BF in the United States. Future studies may explore interventions targeted to modifiable barriers to improve BF outcomes.

Infant Feeding Exposure and Personal Experiences of African American Mothers

Background: Although exposure and personal experiences can guide breastfeeding decisions, the extant research on African American mothers is limited regarding the influence of infant feeding exposure. The persistent race-based breastfeeding disparities also underscore the lack of effective interventions to support breastfeeding among African Americans. Objective: To describe infant feeding exposure and personal experiences of African American mothers in the Midwestern United States with regard to decision making about breastfeeding behavior. Materials and Methods: Thirty individual qualitative interviews using a semistructured interview guide were conducted with African American mothers ≥18 years old with an infant 1-6 months of age. Interviews addressed participants' breastfeeding and formula feeding decisions. Data were coded line by line using thematic analysis. Results: Positive exposure to breastfeeding and health care providers' prenatal advice influenced nearly all participants to try breastfeeding. However, breastfeeding experiences were unexpected, they did not know how to handle challenges, and nearly half did not continue. Five central themes important to their decision-making processes were identified in the data including contact with breastfeeding mothers, guidance from health care providers, navigating the demands of breastfeeding, making the switch to formula, and my own research. Conclusion: Our findings support the importance of both prenatal and postnatal education, the influence of health care providers, and the impact of close social role models. Appropriate education about realistic breastfeeding information is needed to support African American mothers in their breastfeeding decision making. The high use of the Internet to access information also emphasizes the potential opportunity for breastfeeding interventions delivered through technology.

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since BFHI implementation, the racial gap in breastfeeding initiation decreased, but a significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.

Guilt, shame, and postpartum infant feeding outcomes: A systematic review

Negative maternal affect (e.g., depression and anxiety) has been associated with shorter breastfeeding duration and poorer breastfeeding intention, initiation, and exclusivity. Other affective states, including guilt and shame, have been linked with formula feeding practice, though existing literature has yet to be synthesised. A narrative synthesis of quantitative data and a framework synthesis of qualitative and quantitative data were conducted to explore guilt and/or shame in relation to infant feeding outcomes. Searches were conducted on the DISCOVER database between December 2017 and March 2018. The search strategy was rerun in February 2020, together yielding 467 studies. The study selection process identified 20 articles, published between 1997 and 2017. Quantitative results demonstrated formula feeders experienced guilt more commonly than breastfeeding mothers. Formula feeders experienced external guilt most commonly associated with healthcare professionals, whereas breastfeeding mothers experienced guilt most commonly associated with peers and family. No quantitative literature examined shame in relation to infant feeding outcomes, warranting future research. The framework synthesis generated four distinct themes which explored guilt and/or shame in relation to infant feeding outcomes: 'underprepared and ineffectively supported', 'morality and perceived judgement' (breastfeeding), 'frustration with infant feeding care' and 'failures, fears and forbidden practice' (formula feeding). Both guilt and shame were associated with self-perception as a bad mother and poorer maternal mental health. Guilt and shame experiences were qualitatively different in terms of sources and outcomes, dependent on infant feeding method. Suggestions for tailored care to minimise guilt and shame, while supporting breastfeeding, are provided.

She "didn't see my weight; she saw me, a mom who needed help breastfeeding": Perceptions of perinatal weight stigma and its relationship with breastfeeding experiences

Weight stigmatization is related to emotional and psychological distress including low self-esteem, body image dissatisfaction, depression, and anxiety; all linked with suboptimal breastfeeding outcomes. This qualitative descriptive study explored postpartum individuals' recalled experiences of weight stigma during interactions with perinatal healthcare professionals and its perceived influence on their breastfeeding experiences. Semi-structured phone interviews were conducted with (n= 18) participants. Three themes emerged: (1) "Size Doesn't Matter: They Looked Beyond the Scale," (2) "My Self-Confidence and Desire to Breastfeed is More Important than Weight," and (3) "I Was on My Own"-Limited Social Support not Weight Stigma Influenced Breastfeeding.

Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units

Very low birth weight (VLBW; <1500 g birth weight) infants are substantially more likely to be born to black than to non-black mothers, predisposing them to potentially preventable morbidities that increase the risk for costly lifelong health problems. Mothers' own milk (MOM) may be considered the ultimate "personalized medicine" since milk composition and bioactive components vary among mothers and multiple milk constituents provide specific protection based on shared exposures between mother and infant. MOM feedings reduce the risks and associated costs of prematurity-associated morbidities, with the greatest reduction afforded by MOM through to NICU discharge. Although black and non-black mothers have similar lactation goals and initiation rates, black VLBW infants are half as likely to receive MOM at NICU discharge in the United States. Black mothers are significantly more likely to be low-income, single heads of household and have more children in the home, increasing the burden of MOM provision. Although rarely considered, the out-of-pocket and opportunity costs associated with providing MOM for VLBW infants are especially onerous for black mothers. When MOM is not available, the NICU assumes the costs of inferior substitutes for MOM, contributing further to disparate outcomes. Novel strategies to mitigate these disparities are urgently needed. IMPACT: Mother's own milk exemplifies personalized medicine through its unique biologic activity. Hospital factors and social determinants of health are associated with mother's own milk feedings for very low-birth-weight infants in the neonatal intensive care unit. Notably, out-of-pocket and opportunity costs associated with providing mother's own milk are borne by mothers. Conceptualizing mother's own milk feedings as an integral part of NICU care requires consideration of who bears the costs of MOM provision-the mother or the NICU?

The CRIAA Program complex intervention in primary care to support women and their families in breastfeeding: Study protocol for a pilot trial

AIM

To report a pilot study protocol to assess the feasibility of a complex intervention, in the primary healthcare context, to support women and their families in breastfeeding.

DESIGN

A pilot/feasibility trial with control and intervention groups.

METHODS

The study will be conducted in two primary healthcare centres with 40 childbearing women (20 control group; 20 intervention group), with their partner/meaningful person and their respective healthcare professionals. Intervention group participants will receive the intervention: (a) in a breastfeeding workshop during their third trimester of pregnancy; and (b) via virtual breastfeeding support for six months postpartum. Health professionals will be trained to deliver the intervention. The control group will receive standard care in the outpatient clinic. The pilot will help determine the intervention's feasibility. Data collected pre-intervention, 10-days postpartum and two-, four-, and six-months postpartum will provide estimates of the intervention's preliminary effects on self-efficacy and main outcomes. Research Ethics Committee approval was obtained in April 2019.

DISCUSSION

Breastfeeding support is a complex reality influenced by multiple factors. Therefore, approaches to breastfeeding are also, requiring interventions that address its multidimensional nature, including all actors involved. The proposed intervention will be applied by an interdisciplinary professional health team, allowing for its incorporation into standard practice and its perpetual maintenance.

IMPACT

The study will produce an original, comprehensive, complex intervention addressing contextual, and organizational factors to promote breastfeeding support using an interdisciplinary and family-based approach; breastfeeding self-efficacy is the core concept. The program evaluation and feasibility study will permit exploration of the integration of the intervention's novel aspects into the daily work of professionals and reveal how to better use existing resources in a full-scale clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03944642.

Meeting breastfeeding intentions differ by race/ethnicity, Infant and Toddler Feeding Practices Study-2

Prenatal breastfeeding intentions impact breastfeeding practices. Racial/ethnic disparities exist in breastfeeding rates; it is unknown if prenatal intentions and meeting intentions differ by race/ethnicity. A longitudinal cohort of USDA's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) which enrolled participants beginning in 2013 were used to estimate prenatal intentions for breastfeeding initiation, exclusive breast milk feeds at 1 and 3 months by race/ethnicity (n = 2070). Meeting intentions were determined by reported breast milk consumption at birth, 1 month and 3 months. Multivariable logistic regression was used to determine the association of race/ethnicity with meeting intentions. There were no differences in prenatal breastfeeding intentions between non‐Hispanic White and non‐Hispanic Black women (initiation: 86.9% and 87.2%; Month 1: 52.3% and 48.3%; Month 3: 43.8% and 40.9%; respectively), but a higher percentage of Hispanic women intended to breastfeed at all time points (95.5%, 68.3% and 56.4%; respectively, P < 0.05). Among women who intended to breastfeed at Month 1, non‐Hispanic Black and Hispanic women had significantly lower odds of meeting intentions compared with non‐Hispanic White women after adjusting for covariates (aORs: 0.63 [95% CI: 0.41, 0.98]; 0.64 [95% CI: 0.44, 0.92], respectively). Similar findings were seen for Month 3. Despite no differences in breastfeeding intentions, non‐Hispanic Black women were less likely to meet their breastfeeding intentions than non‐Hispanic White women. Hispanic women were more likely to intend to breastfeed yet were less likely to meet their intentions. This suggests that non‐Hispanic Black and Hispanic women face challenges to meeting their longer breastfeeding intentions. Understanding how racism, bias and discrimination contribute to women not meeting their breastfeeding intentions may help efforts to reduce breastfeeding disparities.

Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices

BACKGROUND

Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to 2 health-promoting infant care practices: supine placement and breastfeeding.

METHODS

We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care, which surveyed US mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding.

RESULTS

Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was odds ratio (OR) 1.31 (95% confidence interval [CI] 1.11-1.54) and OR 2.82 (95% CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95% CI 9.00-39.92; breastfeeding: aOR 3.86, 95% CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95% CI 4.52-9.89; breastfeeding: aOR 5.17, 95% CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the 2 practices.

CONCLUSIONS

The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.

Engaging African American Parents to Develop a Mobile Health Technology for Breastfeeding: KULEA-NET

BACKGROUND

African Americans breastfeed less than other groups, which has implications for health throughout the life course. Little is known about mobile health technologies to support breastfeeding.

RESEARCH AIMS

This study proceeded in two phases. The aim of Phase 1 was to identify ideal technological components and content of a mobile health intervention. The aim of Phase 2 was to determine the usability of a prototype, KULEA-NET, based on the Phase 1 findings.

METHODS

For this mixed-methods study, we used community-based participatory research methods and user-centered technology design methods. We used open coding in NVivo 11 to organize data from focus groups and in-depth interviews, then we analyzed the data. We then developed a prototype and tested the prototype's usability with the System Usability Scale. Fifty pregnant and postpartum African Americans from the District of Columbia participated.

RESULTS

Participants preferred an app with text messaging technology and identified areas for intervention: self-efficacy, parent-child attachment beliefs, social support, public breastfeeding and social desirability, and returning to work. Desired features included local resources, support person access, baby care logs, identification of public breastfeeding venues, and peer discussions. The System Usability Scale score was 73.8, which indicates above average usability.

CONCLUSIONS

A mobile health technology like KULEA-NET can be used to meet the breastfeeding needs of African Americans, build social desirability, and complement traditional health care. The appeal of an African American-specific intervention is unclear. Responding to mixed feeding practices is challenging. KULEA-NET is a mobile breastfeeding intervention guided by the preferences of African American parents and offers promising usability metrics.

Sudden Infant Death Syndrome on Facebook: Qualitative Descriptive Content Analysis to Guide Prevention Efforts

Background

Sudden unexpected infant death (SUID), which includes the diagnosis of sudden infant death syndrome (SIDS), is a leading cause of infant mortality in the United States. Despite prevention efforts, many parents continue to create unsafe infant sleep environments and use potentially dangerous infant sleep and monitoring devices, ultimately leading to sleep-related infant deaths. Analyzing Facebook conversations regarding SIDS may offer a unique maternal perspective to guide future research and prevention efforts.

Objective

This study aims to describe and analyze conversations among mothers engaged in discussions about SIDS on a Facebook mother’s group. We were interested in understanding maternal knowledge of SIDS, identifying information sources for SIDS, describing actual infant sleep practices, exploring opinions regarding infant sleep products and monitoring devices, and discovering evidence of provider communication regarding SIDS.

Methods

We extracted and analyzed 20 posts and 912 comments from 512 mothers who participated in a specific Facebook mother’s group and engaged in conversations about SIDS. There were 2 reviewers who coded the data using qualitative descriptive content analysis. Themes were induced after discussion among researchers and after the study objectives were addressed.

Results

The theme of social support emerged, specifically informational and emotional support. A variety of informational sources for SIDS and safe sleep were identified, as was a continuum of infant sleep practices (ranging from unsafe to safe sleep per the American Academy of Pediatrics standards). There was widespread discussion regarding infant sleep products and monitoring devices. Embedded within conversations were (1) confusion among commonly used medical terminology, (2) the practice of unsafe infant sleep, (3) inconsistency in provider communication about SIDS, and (4) maternal anxiety regarding SIDS.

Conclusions

We uncovered new findings in this analysis, such as the commonality of infant sleep products and monitoring devices and widespread maternal anxiety regarding SIDS. Additionally, mothers who participated in the Facebook group provided and received informational and emotional support regarding SIDS via this social media format. Such results can guide future prevention efforts by informing health communication regarding SUID and safe sleep. Future provider and public health agency communication on the topic of SUID and safe sleep should be simple and clear, address infant sleep products and monitoring devices, address maternal anxiety regarding SIDS, and address the common practice of unsafe sleep.

Crucial Contributions : A Biocultural Study of Grandmothering During the Perinatal Period

Maternal grandmothers play a key role in allomaternal care, directly caring for and provisioning their grandchildren as well as helping their daughters with household chores and productive labor. Previous studies have investigated these contributions across a broad time period, from infancy through toddlerhood. Here, we extend and refine the grandmothering literature to investigate the perinatal period as a critical window for grandmaternal contributions. We propose that mother-daughter co-residence during this period affords targeted grandmaternal effort during a period of heightened vulnerability and appreciable impact. We conducted two focus groups and 37 semi-structured interviews with Himba women. Interviews focused on experiences from their first and, if applicable, their most recent birth and included information on social support, domains of teaching and learning, and infant feeding practices. Our qualitative findings reveal three domains in which grandmothers contribute: learning to mother, breastfeeding support, and postnatal health and well-being. We show that informational, emotional, and instrumental support provided to new mothers and their neonates during the perinatal period can aid in the establishment of the mother-infant bond, buffer maternal energy balance, and improve nutritional outcomes for infants. These findings demonstrate that the role of grandmother can be crucial, even when alloparenting is common and breastfeeding is frequent and highly visible. Situated within the broader anthropological and clinical literature, these findings substantiate the claim that humans have evolved in an adaptive sociocultural perinatal complex in which grandmothers provide significant contributions to the health and well-being of their reproductive-age daughters and grandchildren.

Hidden Realities of Infant Feeding: Systematic Review of Qualitative Findings from Parents

A growing, global conversation, regarding realities and challenges that parents experience today is ever-present. To understand recent parent's attitudes, beliefs, and perceptions regarding infant feeding, we sought to systematically identify and synthesize original qualitative research findings. Following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework, electronic databases were searched with a priori terms applied to title/abstract fields and limited to studies published in English from 2015 to 2019, inclusive. Study quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed. Of 73 studies meeting inclusion criteria, four major themes emerged. (1) Breastfeeding is best for an infant; (2) Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident; (3) Infant feeding behaviors are influenced by the socio-cultural environment of the family, and (4) Parent's expectations of education and support addressing personal infant feeding choices from health care providers are not always met. This systematic review, guided by constructs within behavioral models and theories, provides updated findings to help inform the development of nutrition education curricula and public policy programs. Results can be applied within scale-up nutrition and behavioral education interventions that support parents during infant feeding.